How India Allocates Donor Hearts to Foreign Nationals

Roughly a week for the core workup. That includes a right heart catheterisation, with the numbers reviewed at a transplant or VAD meeting or heart failure clinic before we make a call. To meet regulatory requirements we also need a coronary angiogram and a CT scan of the chest, which sizes the device and the pocket it sits in.

A heart failure patient waiting here typically needs a hospital visit about once a fortnight, and hospital and medication expenses run close to $1,500 a month. Across a typical 12 to 14 month wait, that adds up to roughly $20,000 in pre-transplant costs, before the transplant itself.

Just under $50,000 in total. Our package for a foreign national is $45,000 for the transplant plus $5,500 for the pre-transplant workup.

The single most important test is a right heart catheterisation. I want pulmonary vascular resistance under five Wood units, or at least reactive to pulmonary vasodilators, along with the transpulmonary gradient, the pulmonary arterial pressure index against body surface area, and the oxygen step up. Patients with intractable arrhythmias, or more than moderate tricuspid regurgitation with right heart failure symptoms like congestive hepatopathy, are not good candidates. But if the right heart is intact and the failure is confined to the left side from ischaemic disease, that patient is still a strong candidate for an LVAD.

The law is unambiguous that an available organ goes to an Indian citizen first. But there's a specific exception for in-house patients: if an organ becomes available at the same hospital where a foreign national is already admitted, and the regional transplant organisation refuses it or nobody from that region can retrieve it in time, that in-house patient, even if foreign, moves to the top of the list. The hospital only has to inform NOTTO directly, rather than waiting on a no-objection certificate from every regional organisation in the country, a process that can otherwise cost the hours that make an organ unusable.

A foreign national is listed with NOTTO but only becomes eligible for a specific organ once every domestic hospital in the country has refused it for size, shape, blood group or a non-ABO mismatch. That sequencing typically consumes six to seven hours before an organ even reaches a foreign national's consideration, by which point its reliability is already a genuine concern.

Yes. If a hospital where a foreign national is already admitted as an in-house patient is the one offering a donor organ, and the regional transplant organisation declines it or cannot retrieve it in time, that in-house foreign patient becomes the default recipient. The hospital only needs to inform NOTTO directly rather than collecting a no-objection certificate from every regional organisation first.

Five ROTOs cover the north, south, east, west and northeast of the country, sitting below NOTTO in India's three-tier allocation system. The country spans roughly 2,500 km in width and 6,000 km in length, and a donor thoracic organ must be matched, retrieved and transplanted within four to six hours, which is why the regional layer exists.

Largely from in-house donation activity. Trauma and neurology units run structured processes for identifying patients facing brain death or an end-of-life coma, and grief counsellors work with families at that point to discuss donation. This in-house activity, more than the national queue, gives a foreign patient admitted at one of these hospitals a realistic chance of a timely match.